This notice describes how medical
information about you may be used and disclosed and how you can get
access to this information. PLEASE REVIEW IT CAREFULLY.

PROTECTED HEALTH INFORMATION:
Information about your health is private. And it should remain
private. That is why this physician office is required by federal
and state law to protect the privacy of your health information. We
call it “Protected Health Information’ (PHI).

FOR TREATMENT:
During the course of your treatment, we use and disclose your PHI.
For example, if we do visual fields or any other test, our techs may
share the report with your doctor. Or, we will use your PHI to
follow the doctor’s orders for treatment related procedures.

FOR PAYMENT:
After providing treatment, we will ask your insurer to pay us. Some
of your PHI may be entered into our computers in order to send a
claim to your insurance company. This may included a description of
your health problem, the treatment we provided and your membership
number in your employer’s health plan. Or, your insurance may want
to review your medical record to determine whether your care was
necessary. Also, we may disclose to a collection agency some of your
PHI for collecting a bill that you have not paid.

FOR HEALTHCARE OPERATIONS:
Your medical record and PHI could be used in periodic assessments by
physicians about the hospital’s quality of care. Other uses of your
PHI may include business planning or the resolution of a complaint.

SPECIAL USES:
Your relationship to us as a patient might require using or
disclosing your PHI in order to:
a. Remind you of an appointment for treatment
b. Tell you abut treatment alternatives and options
c. Tell you about other health benefits and services
d. Requesting an authorization from your primary care physician for
treatment

YOUR AUTHORIZATION MAY BE REQUIRED:
In many cases, we may use or disclose your PHI, as summarized above,
for treatment, payment, or healthcare operations or as required or
permitted by law. In other cases, we must ask for your written
authorization with specific instructions and limits on our use or
disclosure of your PHI. You may revoke your authorization if you
change your mind later.

CERTAIN USES AND DISCLOSURES OF YOUR PHI REQUIRED OR PERMITTED BY
LAW:
As a healthcare facility, we must abide by many laws and regulations
that either require us or permit us to use or disclose your PHI.

REQUIRED OR PERMITTED USES AND DISCLOSURES:

• 4
If you do not verbally object, we may share some of your PHI with a
family member or friend involved in your care.
• 5
We may use your PHI in an emergency when you are not able to express
yourself
• 6
We may use or disclose your PHI for research if we receive
assurances which protect your privacy

WE MAY ALSO USE OF DISCLOSE YOUR PHI:

• 7
When required by law, for example when ordered by court
• 8
For public health activities including reporting a communicable
disease or adverse drug reaction to the Food and Drug Administration
• 9
To report neglect, abuse, or domestic violence
• 10
To government regulators or agents to determine compliance with
applicable rules and regulations
• 11
In judicial or administrative proceedings as in response to a valid
subpoena
• 12
To a coroner for purposes of identifying a deceased person or
determining cause of death, or to a funeral director for making
funeral arrangements.
• 13
For purposes of research when a research oversight committee, called
an institutional review board, has determined that there is minimal
risk to the privacy of your PHI.
• 14
Fir creating special types of health information that eliminate all
legally required identifying information or information that would
directly identify the subject of the information.
• 15
In accordance with the legal requirements of a workers compensation
program.
• 16
When properly requested by law enforcement officials, for instance
in reporting gun shot would, reporting a suspicious death or for
other legal requirements.
• 17
If we reasonably believe that use or disclosure will avert a health
hazard or to respond to a threat to public safety including an
imminent crime against another person
• 18
For national security purposes including to the Secret Service of if
you are Armed Forces personnel and it is deemed necessary by
appropriate military command authorities.
• 19
In connection with certain types of organ donor programs.

YOUR PRIVACY RIGHTS AND HOW TO EXERCISE THEM:
Under the federally required privacy program, patients have specific
rights.

YOUR RIGHT TO REQUEST LIMITED USE OR DISCLOSURE:
You have the right to request that we do not use or disclose your
PHI in a particular way. However, we are not required to abide by
your request. If we do agree to your request, we must abide by the
agreement.

YOUR RIGHT TO CONFIDENTIAL COMMUNICATION:
You have the right to receive confidential communication from the
physician’s office at a location that you provide. Your request must
be in writing, provide us with the other address and explain if the
request will interfere with your method of payment.

YOUR RIGHT TO REVOKE YOUR AUTHORIZATION:
You may revoke, in writing the authorization you granted us for us
or disclosure of your PHI. However, if we have relied on your
consent to authorization, we may use or disclose your PHI up to the
time you revoke your consent.

YOUR RIGHT TO INSPECT AND COPY:
You have the right to inspect and copy your PHI. We may refuse to
give you access to your PHI if we think it may cause you harm, but
we must explain why and provide you with someone to contact for a
review of our refusal.

YOUR RIGHT TO AMEND YOUR PHI:
If you disagree with your PHI within our records, you have the right
to request, in writing, that we amend your PHI when it is a record
that we created or have maintained for us. We may refuse to make the
amendment and you have a right to disagree in writing. If we still
disagree, we may prepare a counter-statement. Your statement and our
counter-statement must be made part of our record about you.

YOUR RIGHT TO KNOW WHO ELSE SEES YOUR PHI:
You have the right to request an accounting of certain disclosures
we have made on your PHI over the past six years. Requests must be
made after April 14, 2003. We are not required to account for all
disclosures, including those made to you, authorized by you or those
involving treatment, payment, and healthcare operations as described
above. There is no charge for a annual accounting, but there may be
charges for additional accountings. We will inform you if there is a
charge and you have the right to withdraw your request, or pay to
proceed.

WHAT IF I HAVE A COMPLAINT?:
If you believe that your privacy has been violated, you must file a
complaint with us or with the Secretary of Health and Human Services
in Washington, D.C. We will not retaliate or penalize you for filing
a complaint with the facility or the Secretary.

To file a complaint with us, please contact the Office Manager. Your
complaint should provide specific details to help us in
investigating a potential problem.

To file a complaint with the Secretary of Health and Human Services,
write to : 200 Independence Ave., S.E., Washington, D.C. 20201 or
call 1-877-696-6775.

SOME OF OUR PRIVACY OBLIGATIONS AND HOW WE FULFILL THEM:
Federal health information privacy rules require us to give you
notice of our privacy practices. This document is our notice. We
will abide by the privacy practices set forth in this notice.
However, we reserve the right to change this notice and our privacy
practices when permitted or as required by law.

If we change our notice of privacy practices, we will provide our
revised notice to you when you seek treatment from us.

COMPLIANCE WITH CERTAIN STATE LAWS:
When we use or disclose your PHI as described in this notice, or
when you exercise certain rights set forth in this notice, we may
apply state laws about the confidentiality of health information in
place of federal privacy regulations. We do this when these state
laws provide you with greater rights or protection for your PHI.
When state laws are not in conflict or if these laws do not offer
you better rights or more protection, we will continue to protect
your privacy by applying the federal regulations.